<? if ($this->show_form): ?>
<div class="row-fluid">
      <form class="form-horizontal" method="POST">
	    <input type="hidden" value="details" name="card">
	    <input type="hidden" value="<?= $this->bulkCredit ?>" name="bulkCredit">

        <fieldset>
          <div id="legend">
            <legend class="">Payment</legend>
          </div>

          <!-- Name -->
          <div class="control-group">
            <label class="control-label" for="username">Card Holder's Name</label>
            <div class="controls">
              <input type="text" id="username" name="username" placeholder="" class="input-xlarge" value="<?= $_POST['username'] ?>">
            </div>
          </div>
     
          <!-- Card Number -->
          <div class="control-group">
            <label class="control-label" for="card_number">Card Number</label>
            <div class="controls">
              <input type="text" id="card_number" name="card_number" placeholder="" class="input-xlarge" value="<?= $_POST['card_number'] ?>">
            </div>
          </div>
     
          <!-- Expiry-->
          <div class="control-group">
            <label class="control-label" for="password">Card Expiry Date</label>
            <div class="controls">
              <select class="span3" name="expiry_month" id="expiry_month">
                <option></option>
                <option value="1">Jan (01)</option>
                <option value="2">Feb (02)</option>
                <option value="3">Mar (03)</option>
                <option value="4">Apr (04)</option>
                <option value="5">May (05)</option>
                <option value="6">June (06)</option>
                <option value="7">July (07)</option>
                <option value="8">Aug (08)</option>
                <option value="9">Sep (09)</option>
                <option value="10">Oct (10)</option>
                <option value="11">Nov (11)</option>
                <option value="12">Dec (12)</option>
              </select>
              <select class="span2" name="expiry_year">
				<? for ($y = date("Y") ; $y < date("Y")+10; $y++): ?>
                  <option value="<?= $y ?>"><?= $y ?></option>
				<? endfor; ?>
              </select>
            </div>
          </div>

          <!-- CVV -->
          <div class="control-group">
            <label class="control-label" for="password_confirm">Card CVV</label>
            <div class="controls">
              <input type="password" id="password_confirm" name="password_confirm" placeholder="" class="span2">
            </div>
          </div>

          <!-- Submit -->
          <div class="control-group">
            <div class="controls">
              <button class="btn btn-success">Pay Now</button>
            </div>
          </div>

        </fieldset>
      </form>
</div>
<? endif; ?>
